Successful Obliteration of a Ruptured Partially Thrombosed Giant M1 Fusiform Aneurysm with Coil Embolization at Distal M1 after Extracranial-Intracranial Bypass

Abstract

Proximal occlusion or trapping combined with EC-IC bypass is usually employed as a definite treatment for a giant fusiform aneurysm in cases where it is impossible to apply clips and do vascular reconstruction. Endovascular treatment is very important as an alternative or combined technique if direct surgery is impossible. The authors report a young male who presented with a 2^nd episode of intracranial bleeding in basal ganglion and subarachnoid hemorrhage with mild right hemiparesis. His 3D-CT scan revealed left ruptured partially thrombosed giant M1 fusiform aneurysm and left unruptured C3 saccular aneurysm. He underwent STA-MCA bypass with attempted M1 reconstruction and a week later attempted total occlusion of the M1 aneurysm with coils. But only a ruptured point at the distal M1 was occluded which, however, resulted in temporary mild right hemiparesis and aphasia. A month later when he was supposed to have his 2^nd coiling procedure his angiogram demonstrated spontaneous and complete obliteration of both the M1 and C3 aneurysms without any new neurological deficit, so no further endovascular procedure was attempted. The discussion is based on this case and previous reports regarding difficult giant M1 fusiform aneurysms, its treatment and spontaneous thrombosis of aneurysmal sac after bypass and distal occlusion. Conclusions are drawn that 1) spontaneous thrombosis of M1 and C3 aneurysms should be the result of hemodynamic alteration in both aneurysms due to a lower flow velocity induced by distal bypass and distal occlusion of M1, 2) combined distal bypass and endovascular obliteration of the aneurysmal sac with coils is a good alternative if vascular reconstruction is difficult or impossible.

Key words

Giant Fusiform Aneurysm - Spontaneous and Complete Thrombosis - Flow Alteration - Coil Embolization

References

• 1 Fujii K, Fukui M, Matsubara T, Nagata S, Fujiwara S, Matsushima T, Hasuo K. Microsurgical procedures for management of giant middle cerebral aneurysm causing increased intracranial pressure.  Surg Neurol. 1989;  32 366-711
• 2 Steiberg G K, Drake C G, Peerless S J. Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms - immediate results and long term outcome in 201 patients.  J Neurosurg. 1993;  79 161-173
• 3 Drake C G, Peerless S J, Ferguson G G. Hunterion proximal arterial occlusion for giant aneurysms of the carotid circulation.  J Neurosurg. 1994;  81 656-665
• 4 Anson J A, Lawton M T, Spetzler R F. Characteristic and surgical treatment of dolichoectatic and fusiform aneurysms.  J Neurosurg. 1996;  84 185-193
• 5 Drake C G, Peerless S J. Giant fusiform intracranial aneurysms: review of 120 patients treated surgically from 1965 to 1992.  J Neurosurg. 1997;  87 141-162
• 6 Amin-Hanjani S, Ogilvi C S, Buonanno F S, Choi I S, Metz L N. Treatment of dissecting basilar artery aneurysm by flow reversal.  Acta Neurochir (Wien). 1997;  139 44-51
• 7 Sano H, Kato Y, Shankar K, Kanaoka N, Hayakawa M, Katada K, Kanno T. Treatment and result of partially thrombosed giant aneurysms.  Neurol Med Chir Suppl (Tokyo). 1998;  38 80-83
• 8 Sinson G, Philips M F, Flamm E S. Intraoperative endovascular surgery for cerebral aneurysms.  J Neurosurgery. 1996;  84 63-70
• 9 Serbinenko F A, Filatov J M, Spallone A, Tchurilov M V, Lazarev V A. Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion.  J Neurosurg. 1990;  73 57-63
• 10 Gobin Y, Vinulla F, Gurian J H, Guglielmi G, Duckwiler G R, Massoud T F, Martin N A. Treatment of large and giant fusiform intracranial aneurysms with Guglilmi detachable coils.  J Neurosurg. 1996;  84 55-62
• 11 Higashida T R, Smith W, Gress D, Urwin R, Dowd C F, Balousek P A, Halbach V V. Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery: case report and review of literature.  J Neurosurg. 1997;  87 944-949
• 12 Sano H, Kato Y, Singh F B, Abdeen K, Kanaoka K, Katada K, Kanno T. Combined treatment with direct surgery and interventional coil embolization for difficult aneurysms.  Surgery for Cerebral Stroke. 1999;  27 172-182
• 13 Hoh P L, Putman C M, Budzik R F, Carter B S, Ogilvy C S. Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization.  J Neurosurg. 2001;  95 24-35
• 14 Steiger H J, Poll A, Liepsch D, Reulen H J. Haemodynamic stress in lateral saccular aneurysms.  Acta Neurochir (Wien). 1987;  86 98-105
• 15 Steiger H J, Poll A, Liepsch D, Reulen H J. Haemodynamic stress in terminal aneurysms.  Acta Neurochir (Wien). 1988;  93 18-23
• 16 Soichiro K, Hashimoto N, Kikuchi H, Fumitada H, Nagata I, Kataoka H. Cerebral aneurysms arising at non branching sites: an experimental study.  Stroke. 1997;  28 398-404
• 17 Forbus W D. On the origin of military aneurysms of the superficial cerebral arteries.  Bull Johns Hopkins Hosp. 1930;  47 239-284
• 18 Kayembe K NT, Sasahara M, Hazama F. Cerebral aneurysms and variations of the circle of Willis.  Stroke. 1984;  15 846-850
• 19 Stehbens W E. Etiology of intracranial berry aneurysms: review article.  J Neurosurg. 1989;  70 823-831
• 20 Tognetti F, Limoni P, Testa C. Aneurysm growth and hemodynamic stress.  Surg Neurol. 1983;  20 74-78
• 21 Hashimoto N, Handa H, Nagata I, Hazama F, Hashimoto N, Handa H, Nagata I, Hazama F. Experimental cerebral aneurysms with reference to the experimental condition and to the etiology.  Neuromed Chir. 1979;  19 999-1003
• 22 Hashimoto N, Handa H, Nagata I, Hazama F. Experimentally induced cerebral aneurysms in rats: part 5, relation of hemodynamics in the circle of Willis to formation of aneurysms.  Surg Neurol. 1980;  13 41-45
• 23 Nagata I, Handa H, Hashimoto N, Hazama F. Experimentally induced cerebral aneurysms in rats 7, scanning electron microscope study.  Surg Neurol. 1981;  16 291-296
• 24 Stehbens W E. Hemodynamically induced atrophic lesions of atherosclerosis. In: Lieepsch DW (ed). Proceedings of the 2nd. International symposium on biofluid mechanics and biorheology Basel: Karger 1989
• 25 Foutrakis G N, Yonas H, Sclabassi R J. Saccular aneurysm formation in curved and bifurcating arteries.  AJNR. 1999;  20 1309-1317
• 26 Lavyne M H, Kleefield J, Dvis K R. Giant intracranial aneurysms of the anterior circulation: clinical characteristics and diagnosis by computed tomography.  Neurosurgery. 1978;  3 356-363
• 27 Pinto R S, Kricheff I I, Butter A R, Murai R. Correlation of computed tomograpic, angiographic and neuropathological changes in giant cerebral aneurysms.  Radiology. 1979;  132 85-92
• 28 Whittle I R, Dorsch N W, Besser M. Spontaneous thrombosis in giant intracranial aneurysms.  J Neurol Neurosurg Psychiatry. 1982;  45 1040-1047
• 29 Fukuoka S, Suematsu K, Fujiwara H, Hashimoto I, Nakamura J-I. Completely thrombosed giant aneurysm of angular artery.  Surg Neurol. 1984;  22 145-148
• 30 Marchau M MB, Vallaeys J, Vanhoonen G. Thrombosis of a giant aneurysm of basilar artery.  Neurosurgery. 1988;  22 612-613
• 31 Benashvili G M, Alexander L F, Zubkov Y N. Thrombosis of giant aneurysm after extracranial-intracranial bypass.  Neurosurgery. 1992;  31 360-364
• 32 Yeh H-S, Tomsick T A. Obliteration of giant carotid aneurysm after extracranial to intracranial bypass surgery: case report.  Surg Neurol. 1997;  48 473-476
• 33 Heros R C, Ameri A M. Rupture of a giant basilar aneurysm after saphenous vein interposition graft to the posterior cerebral artery: case report.  J Neurosurg. 1984;  61 387-390
• 34 Anson J A, Stone L J, Crowell R M. Rupture of giant carotid aneurysm after extracranial to intracranial bypass surgery.  Neurosurgery. 1991;  28 142-147
• 35 Hopkins L N, Walter G. Extracranial-intracranial arterial bypass in the treatment of aneurysms of the carotid and middle cerebral arteries.  Neurosurgery. 1979;  5 21-31
• 36 Scott R M, Liu H C, Yuan R, Adelman L. Rupture of previously unruptured giant middle cerebral artery aneurysm after extracranial-intracranial bypass surgery.  Neurosurgery. 1982;  10 600-603